Narcolepsy - Treatment

Treatment

Patients with narcolepsy can be substantially helped, but not cured. Treatment is tailored to the individual, based on symptoms and therapeutic response. The time required to achieve optimal control of symptoms is highly variable, and may take several months or longer. Medication adjustments are frequently necessary, and complete control of symptoms is seldom possible. While oral medications are the mainstay of formal narcolepsy treatment, lifestyle changes are also important.

The main treatment of excessive daytime sleepiness in narcolepsy is central nervous system stimulants such as methylphenidate, amphetamine, methamphetamine, modafinil (Provigil), a new stimulant with a different pharmacologic mechanism, and/or armodafinil (Nuvigil). In Fall 2007 an alert for severe adverse skin reactions to modafinil was issued by the FDA. Other medications used are codeine and selegiline. Another drug that is used is atomoxetine (Strattera), a non-stimulant and norepinephrine reuptake inhibitor (NRI), that has little or no abuse potential. In many cases, planned regular short naps can reduce the need for pharmacological treatment of the EDS but only improve symptoms for a short duration. A 120 minute nap provided benefit for 3 hours in patient alertness where as a 15 minute provided no benefit.

Cataplexy and other REM-sleep symptoms are frequently treated with tricyclic antidepressants such as clomipramine, imipramine, or protriptyline, as well as other drugs that suppress REM sleep. Venlafaxine (branded as Effexor XR by Wyeth Pharmaceuticals), an antidepressant which blocks the reuptake of serotonin and norepinephrine, has shown usefulness in managing symptoms of cataplexy, however, it has notable side-effects including sleep disruption.

Another treatment option for narcolepsy is Xyrem (sodium oxybate) oral solution. Xyrem is a prescription medication manufactured by Jazz Pharmaceuticals, and is approved by the U.S. Food and Drug Administration (FDA) for the treatment of cataplexy associated with narcolepsy and Excessive Daytime Sleepiness (EDS) associated with narcolepsy. The American Academy of Sleep Medicine (AASM) recently recognized Xyrem as a standard of care for the treatment of cataplexy, daytime sleepiness, and disrupted sleep due to narcolepsy in its Practice Parameters for the Treatment of Narcolepsy and other Hypersomnias of Central Origin.

Using stimulants to mask daytime sleepiness does not address the actual cause of the problem. Stimulants may provide some assistance with daytime activity, but the underlying cause will remain and potentially worsen over time due to the stimulant itself becoming an obstruction to delta wave sleep periods. Lifestyle changes involving reduced stress, more exercise (especially for overweight persons experiencing EDS caused by sleep apnea and snoring) and less stimulant intake (such as coffee and nicotine) are likely to be ideal forms of assistive treatment. Some people with narcolepsy have a nocturnal body clock and are helped by selecting an occupation that properly coincides with their body's natural sleep cycle (such as sleeping in the day and working at night). This allows sufferers to avoid the need to force themselves into the more common 9 to 5 schedule that their body is unable to maintain, and avoids the need to take stimulants to remain active during the times when their bodies are inclined to rest.

In addition to drug therapy, an important part of treatment is scheduling short naps (10 to 15 minutes) two to three times per day to help control excessive daytime sleepiness and help the person stay as alert as possible. Daytime naps are not a replacement for nighttime sleep, especially if a person's body is natively inclined towards a nocturnal life cycle. Ongoing communication between the health care provider, patient, and the patient's family members is important for optimal management of narcolepsy.

Finally, a recent study reported that transplantation of hypocretin neurons into the pontine reticular formation in rats is feasible, indicating the development of alternative therapeutic strategies in addition to pharmacological interventions.